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ONI RING SYSTEM CERTIFIOATION For Use By All Jurisdictions Within the State of California Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of Regulations This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date. A. General Information Facility Name: Site Address: Facility Contact Person: SOUTH BAY TIRE 1501 W. CHARTER WAY STOCKTON, CA 95206 Contact Phone No.: Bldg. No.: _ Zip: - Make/Model of Monitoring System: `� �Q�1� %,ad.C1J Date of Testing/Servicing: (V,, B. Inventory of Equipment Tested/Certified Check the appropriate boxes to indicate specific equipment inspected/serviced: Tank ID: Tank ID: In -Tank Gauging Probe. Model: ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: t a ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: a, ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). & Mechanical Line Leak Detector. Model: ❑ Fill Sump Sensor(s). Model: Model: ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: 0 Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model:. ❑ Other �specity equipment e and model 4f Section E on Pa e 2). ❑ Others eci a ui ent e and model in Section E on PHS 2L Tank ID: t .. Tank ID: In -Tank Gauging Probe. Model: -C ❑ In -Tank Gauging Probe. Model: Annular Space or Vault Sensor. Model: _t� _ ❑ Annular Space or Vault Sensor. Model: Piping Sump / Trench Sensor(s). Model: r 0 ❑ Piping Sump / Trench Sensor(s). Model: ❑ Fill Sump Sensor(s). Model: 0 ❑ Fill Sump Sensor(s). Model: ® Mechanical Line Leak Detector. Model: -i.:' ❑ Mechanical Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: ❑ Electronic Line Leak Detector. Model: iQ• Tank Overfill / High -Level Sensor. Model: ❑ Tank Overfill / High -Level Sensor. Model: ❑ Other (specia Nuipment!X2S=andd model in Section E on Pa e 2 . ❑ Others eci a ui ment e and model in Section E on Pae 2). Dispenser ID: Dispenser ID: — 7--,"-- U Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s), Dispenser Containment (P Shear Valve(s). Floats and Chain(s). TJ Dispenser Containment Floats and Chains . Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: RE Shear Valve(s). 41 Shear Valve(s). -Dispenser Containment Flo2�ts2 and Chains . Di enser Containment Floats and Chain(s). Dispenser ID: Dispenser ID: ❑ Dispenser Containment Sensor(s). Model: ❑ Dispenser Containment Sensor(s). Model: Shear Valve(s). El Shear Valve(s). Dis enser Containment Floats and Chain(s). ❑ Dis enser Containment Floats and Chains . li the taciiity contains more tanks or dispensers, copy this tbrm. Include information for every tank and dispenser at the facility. C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers' guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct and a Plot Plan showing the layout of monitoring equipment. For any a 'pment capable of generating such reports, I have also attac e a copy f he report- (check all that apply): ❑ Sya et -up I Alarm his ory report Technician Name (print): CJ�j k (d`•n�-= _ Signature: Certification No.; License, No,; Testing Company Name: TANK-TEK ENVIRONMENTAL CORPORATION Site Address: 115Q V1 . CV�ar Phone No.: (707) 446--6151 Date of Testing/Servicing: I()/, � __0 Page 1 of 3 03/01 Monitoring System Certification